WHO Safe Childbirth Checklist Implementation Guide

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WHO SAFE CHILDBIRTH CHECKLIST IMPLEMENTATION GUIDE 1

BACKGROUND AND OVERVIEW

WHO Safe Childbirth Checklist Implementation Guide

Improving the quality of facility-based delivery

for mothers and newborns

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WHO Library Cataloguing-in-Publication Data

WHO safe childbirth checklist implementation guide: improving the quality of facility-based delivery for mothers and newborns.

1.Parturition. 2.Birthing Centers. 3.Perinatal Care. 4.Maternal Health Services. 5.Infant, Newborn. 6.Quality of Health Care. 7.Checklist. I.World Health Organization.

ISBN 978 92 4 154945 5 (NLM classification: WQ 300)

© World Health Organization 2015

All rights reserved. Publications of the World Health Organization are available on the WHO web site (www.who.int) or can be purchased from WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel.: +41 22 791 3264; fax: +41 22 791 4857;

e-mail: bookorders@who.int).

Requests for permission to reproduce or translate WHO publications—whether for sale or for non-commercial distribution—should be addressed to WHO Press through the WHO website (www.who.int/about/licensing/copyright_form/en/index.html).

The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organiza- tion concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement.

The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters.

All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distrib- uted without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use.

Design and layout by Complex Stories, Boston, USA

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WHO Safe Childbirth Checklist Implementation Guide

Improving the quality of facility-based delivery

for mothers and newborns

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C ONTENT S Introduction to the Implementation Guide 6 20 14

Annexes 30

Glossary 46

Description of Checklist Items References Acknowledgements

Safe Birth Supplies Guide to holding a launch event

WHO Safe Childbirth Checklist pause point illustrations Principles of effective coaching

Observation tool Coaching tool

8

8

8 10 11

21

24 25

30 32 34

36 39 43

Background & Overview of the WHO Safe Childbirth Checklist

Checklist development Evidence from testing Overview of the WHO Safe Childbirth Checklist

Tips on using the Checklist

The WHO Safe Childbirth Checklist

Implementing the WHO Safe Childbirth Checklist

Engage Launch Support

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60 61

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WHO SAFE CHILDBIRTH CHECKLIST IMPLEMENTATION GUIDE 5

BACKGROUND AND OVERVIEW

INTRODUCTION

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INTRODUCTION

WHO SAFE CHILDBIRTH CHECKLIST IMPLEMENTATION GUIDE 6 In 2013, 289 000 women died during and following pregnancy and childbirth, and

2.8 million newborns died within 28 days of birth. The majority of these deaths occurred in low-resource settings and most could have been prevented.1

Childbirth is a complex process, and it is essential to remember to provide everything that is needed to ensure both the mother and newborn child receive the safest care possible. Checklists are useful tools to organize such complex, and important processes

— they have long been used to prompt users to remember essential tasks to deliver better and safer care in a variety of settings.1,2

The WHO Safe Childbirth Checklist was designed as a tool to improve the quality of care provided to women giving birth. The Checklist is an organized list of evidence -based essential birth practices, which targets the major causes of maternal deaths, intrapartum-related stillbirths and neonatal deaths that occur in health-care facilities around the world. Each Checklist item is a critical action that, if missed, can lead to severe harm for the mother, the newborn, or both.

Experience with other patient safety tools, including the WHO Surgical Safety Checklist, highlights that simply offering a checklist to a health-care worker or demanding that a facility or system use a patient safety tool does not result in widespread, consistent use of the checklist or tool. Nor do such strategies lead to improved care for patients.2 As a result, this guide has been developed to help birth attendants and health-care leaders successfully use the WHO Safe Childbirth Checklist. We have drawn on lessons learned by a wide range of health-care professionals who have tested, used, and championed the Checklist across the world.

Development, use and implementation of the Checklist are described in this guide.

It covers how to introduce and ensure continuous use of the Checklist by engaging relevant stakeholders, how to launch the Checklist formally, and how to provide support through coaching and data-sharing. The annexes provide a more detailed description of the Checklist items, as well as useful resources to complement the implementation approach described.

THIS IMPLEMENTATION GUIDE AND THE WHO SAFE CHILDBIRTH CHECKLIST ARE ALSO AVAILABLE ONLINE AT:

www.who.int/patientsafety/

implementation/checklists/

childbirth/

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WHO SAFE CHILDBIRTH CHECKLIST IMPLEMENTATION GUIDE 7

BACKGROUND AND OVERVIEW

BACKGROUND

& OVERVIEW

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WHO SAFE CHILDBIRTH CHECKLIST IMPLEMENTATION GUIDE 8

BACKGROUND AND OVERVIEW

Childbirth is a complex process with many necessary, sometimes difficult, sometimes complicated steps that ensure both the mother and her newborn child receive the safest care possible. Most people find it difficult to simply remember all of the relevant information;

actually performing all the steps correctly and in the correct order is even more challenging.

But in settings from restaurants to construction sites, from airplanes to hospitals, professionals are successfully using checklists to organize and order large amounts of complex informa- tion, to remind themselves to perform crucial duties, and to ultimately do their jobs more effectively, efficiently and safely.3

Checklist development

With this evidence in mind, the World Health Organization — with input from nurses, mid- wives, obstetricians, paediatricians, general practitioners, patient safety experts and patients from around the world — developed the WHO Safe Childbirth Checklist (the Checklist) to help health-care workers provide high quality care during births in health facilities, from the moment the mother arrives to the moment the mother and her newborn leave the facility.3,4

The Checklist is a list of evidence-based practices, organized into four different pause points.

Based on WHO guidelines, the items on the Checklist help prevent the major worldwide causes of maternal deaths, intrapartum-related stillbirths and neonatal deaths (including haemorrhage, infection, obstructed labour and hypertensive disorders and complications of prematurity). Each task on the Checklist is a crucial action that, if missed, can result in severe harm for the mother, the newborn, or both.

Evidence from testing

The World Health Organization has tested the Checklist extensively. The pilot edition of the WHO Safe Childbirth Checklist underwent field evaluation in nine countries, providing thorough feedback. WHO used that feedback to revise the Checklist, and it was then field-tested in Karnataka State, India. It was found that the delivery of evidence-based essential birth practices at each birth event increased from an average of 10 out of 29 practices prior to introduction of the Checklist to an average of 25 out of 29 practices after the Checklist had been introduced.2

Following this pilot study in Karnataka, a large randomized control trial was designed to follow 116 000 births across Uttar Pradesh, the most populous state in India. This trial – the BetterBirth Programme – which is still ongoing, will determine the effect of a successful Checklist introduc- tion on maternal and neonatal health outcomes. Preliminary results from the first five facilities participating in the BetterBirth programme are promising. Before the Checklist was introduced, the facilities performed only five of the 17 birth practices measured in the trial. However, after BetterBirth introduced the Checklist – using many of the tools and strategies introduced here – birth attendants in the facilities performed 16 of the birth practices consistently. In Rajasthan, India, Jhpiego, with support from the Children’s Investment Fund Foundation (CIFF) and in partnership with Government of Rajasthan have used the checklist in 101 public facilities.

THE IMPORTANCE OF THE CHECKLIST:

These safe childbirth practices have been proven to reduce maternal and newborn harm.

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WHO SAFE CHILDBIRTH CHECKLIST IMPLEMENTATION GUIDE 9

BACKGROUND AND OVERVIEW

Initial results in the Jhpiego program have demonstrated improved quality of care in public sector facilities and state of Andhra Pradesh and Gujarat have already introduced the checklist in several public health facilities.

Alongside these efforts to test the Checklist, WHO, in partnership with Ariadne Labs, estab- lished the WHO Safe Childbirth Checklist Collaboration (the WHO Collaboration) to explore the circumstances that influence use of the Checklist around the world. From November 2012 to March 2015, thirty-four groups registered projects with the WHO Collaboration, covering 29 countries and 234 sites. Groups explored many questions concerned with how and why some facilities used the Checklist readily, effectively, and consistently, while others did not.

To gather and document the lessons learned by these 34 groups, a comprehensive survey about the introduction and use of the checklist was conducted.

representing and .

registered projects with the Collaboration, 34

GROUPS

COUNTRIES

29 234

SITES

From November 2012 through March 2015 a total of

DELIVERY PROCESS ONGOING CARE

THE RIGHT MOMENTS TO PAUSE AND CHECK

The WHO Safe Childbirth Checklist is intended for use at four pause points during facility-based births:

DELIVERY DISCHARGE

ADMISSION PAUSE POINT 1: ON ADMISSION

Checking the mother at the time of admission is important to detect and treat complications that she may already have, to confirm whether she needs to be referred to another facility, to prepare her (and her companion) for labour and delivery, and to educate her (and her companion) about danger signs for which she should call for help.

PAUSE POINT 2: JUST BEFORE PUSHING (or before Caesarean)

Checking the mother just before pushing (or before Caesarean) is important to detect and treat complications that can occur during labour and to prepare for routine events and possible crisis situations that may occur after birth.

PAUSE POINT 3: SOON AFTER BIRTH (within one hour)

Checking the mother and newborn soon after birth (within 1 hour) is important to detect and treat complications that can occur after delivery, and to educate the mother (and her companion) about danger signs for which she should call for help.

PAUSE POINT 4: BEFORE DISCHARGE

Checking the mother and newborn before discharge is important to be sure that the mother and newborn are healthy before discharge, that follow-up has been arranged, that family planning options have been discussed and offered to the mother (and her companion), and that education on danger signs to look out for, both in the mother and her baby, has been given in case immediate skilled care is needed.

1 2 3 4

CHECKLIST Referral

Criteria

CHECKLIST Referral

Criteria

CHECKLIST Danger

Signs

CHECKLIST

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WHO SAFE CHILDBIRTH CHECKLIST IMPLEMENTATION GUIDE 10

BACKGROUND AND OVERVIEW

The results of this survey greatly improved understanding of how to make the WHO Safe Child- birth Checklist most effective in improving care for mothers and newborns in settings around the world. Many of these lessons and experiences from the survey are shared in this guide.

Overview of the WHO

Safe Childbirth Checklist

The WHO Safe Childbirth Checklist helps health-care workers ensure that essential birth practices are performed at critical moments during childbirth for every delivery, every time.

Childbirth is characterized by events that are both routine and unexpected, and complica- tions for the mother, the newborn, or both can happen unpredictably. While it is not possible to list on a single checklist all practices that are required at each birth, the Checklist does list a core set of practices that have been proven to reduce harm to mothers and newborns.

In designing the Checklist, routine flow of events were considered and essential birth prac- tices were streamlined into four sections. The four sections, or pause points, are specific points in time when birth attendants should “check” that they have completed essential birth practices. These pause points allow birth attendants to make their “checks” at times when they can protect the mother and newborn against dangerous complications, but the pause points also take place when it is convenient for birth attendants to take the time to perform the checks.

Each item on the WHO Safe Childbirth Checklist is described in more detail in the GLOSSARY.

DELIVERY PROCESS ONGOING CARE

THE RIGHT MOMENTS TO PAUSE AND CHECK

The WHO Safe Childbirth Checklist is intended for use at four pause points during facility-based births:

DELIVERY DISCHARGE

ADMISSION PAUSE POINT 1: ON ADMISSION

Checking the mother at the time of admission is important to detect and treat complications that she may already have, to confirm whether she needs to be referred to another facility, to prepare her (and her companion) for labour and delivery, and to educate her (and her companion) about danger signs for which she should call for help.

PAUSE POINT 2: JUST BEFORE PUSHING (or before Caesarean)

Checking the mother just before pushing (or before Caesarean) is important to detect and treat complications that can occur during labour and to prepare for routine events and possible crisis situations that may occur after birth.

PAUSE POINT 3: SOON AFTER BIRTH (within one hour)

Checking the mother and newborn soon after birth (within 1 hour) is important to detect and treat complications that can occur after delivery, and to educate the mother (and her companion) about danger signs for which she should call for help.

PAUSE POINT 4: BEFORE DISCHARGE

Checking the mother and newborn before discharge is important to be sure that the mother and newborn are healthy before discharge, that follow-up has been arranged, that family planning options have been discussed and offered to the mother (and her companion), and that education on danger signs to look out for, both in the mother and her baby, has been given in case immediate skilled care is needed.

1 2 3 4

CHECKLIST Referral

Criteria

CHECKLIST Referral

Criteria

CHECKLIST Danger

Signs

CHECKLIST

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WHO SAFE CHILDBIRTH CHECKLIST IMPLEMENTATION GUIDE 11

BACKGROUND AND OVERVIEW

Each Checklist item is important for every mother and every delivery — birth attendants must always refer to the Checklist at each pause point, even if they are confident in their knowledge of birth practices

Birth attendants should use one Checklist for each mother, and that Checklist should follow the mother and baby from location to location and birth attendant to birth attendant

Though the Checklist may seem complicated and time-consuming at first, it will soon allow birth attendants to perform essential birth practices more easily, safely, and quickly

TIPS ON USING THE WHO SAFE CHILDBIRTH CHECKLIST

In many health facilities, the pause points will not take place in the same location. For in- stance, pause point 1 may take place at the admission desk, pause point 2 may take place in the labour room, pause point 3 may take place in the postpartum bay, and pause point 4 may take place on the postpartum ward. In facilities with only a labour room, all pause points may occur in that place. Each facility should determine, based on their own needs and practices, where birth attendants will conduct their checks during each of the four pause points. If the pause points take place in separate locations, then the Checklist must “follow”

the mother and newborn as they move from room to room. In many situations, keeping the Checklist with the mother’s chart or medical record will allow the birth attendant to find it more easily when she needs it.

Tips on using the WHO Safe Childbirth Checklist

Checklists can commonly be used in two ways: in “Read-Do,” you first read the item on the Checklist, then complete the task. In “Do-Confirm,” you complete the task then read the item on the Checklist to confirm that you have done it. You may use either method, though many find the “Read-Do” method easier to carry out, especially those who are new to using the Checklist.

To further help birth attendants, the Checklist includes additional information located to the right of each item. For instance, for the item related to the partograph, the Checklist offers a description of how a partograph should be used. Birth attendants should refer to this supple- mentary information as needed. After repeatedly using the Checklist, birth attendants may memorize this information, however, birth attendants should carry on using the WHO Safe Childbirth Checklist at every pause point during each delivery, in order to ensure that they are always performing all the essential birth practices, every time.

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WHO SAFE CHILDBIRTH CHECKLIST IMPLEMENTATION GUIDE 12

BACKGROUND AND OVERVIEW

Several Checklist items require administering medications such as antibiotics, magnesium sulfate, antihypertensives, and oxytocin. The Checklist does not list specific antibiotics, anti- hypertensives because guidelines used across the world may require different pharmaceuti- cals in different locations. In adapting the Checklist to your facility, select antibiotics accord- ing to your nation’s or to WHO’s guidelines. Similarly, plan dosages and treatment courses for all medications according to these guidelines.

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WHO SAFE CHILDBIRTH CHECKLIST IMPLEMENTATION GUIDE 13

BACKGROUND AND OVERVIEW

THE WHO SAFE CHILDBIRTH

CHECKLIST

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On Admission

WHO Safe Childbirth Checklist

BEFORE BIRTH

WHO Safe Childbirth Checklist

Check your facility’s criteria

Call for help if any of:

• Bleeding

• Severe abdominal pain

• Severe headache or visual disturbance

• Unable to urinate

• Urge to push

Ask for allergies before administration of any medication Give antibiotics to mother if any of:

• Mother’s temperature ≥38°C

• History of foul-smelling vaginal discharge

• Rupture of membranes >18 hrs

Give magnesium sulfate to mother if any of:

• Diastolic BP ≥110 mmHg and 3+ proteinuria

• Diastolic BP ≥90 mmHg, 2+ proteinuria,

and any: severe headache, visual disturbance, epigastric pain Give antihypertensive medication to mother if systolic BP >160 mmHg

• Goal: keep BP <150/100 mmHg Does mother need referral?

No

Yes, organized Partograph started?

No, will start when ≥4cm Yes

Does mother need to start:

Antibiotics?

No Yes, given

Magnesium sulfate and antihypertensive treatment?

No

Yes, magnesium sulfate given

Yes, antihypertensive medication given

Confirm supplies are available to clean hands and wear gloves for each vaginal exam.

Encourage birth companion to be present at birth.

Confirm that mother or companion will call for help during labour if needed.

Completed by

Start plotting when cervix ≥4 cm, then cervix should dilate ≥1 cm/hr

• Every 30 min: plot HR, contractions, fetal HR

• Every 2 hrs: plot temperature

• Every 4 hrs: plot BP

This checklist is not intended to be comprehensive and should not replace the case notes or partograph. Additions and modifications to fit local practice are encouraged.

For more information on recommended use of the checklist, please refer to the “WHO Safe Childbirth Checklist Implementation Guide” at: www.who.int/patientsafety.

© WHO 2015 WHO/HIS/SDS/2015.26

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WHO Safe Childbirth Checklist

Just Before Pushing (Or Before Caesarean)

WHO Safe Childbirth Checklist

Ask for allergies before administration of any medication Give antibiotics to mother if any of:

• Mother’s temperature ≥38 °C

• History of foul-smelling vaginal discharge

• Rupture of membranes >18 hrs

• Caesarean section

Give magnesium sulfate to mother if any of:

• Diastolic BP ≥110 mmHg and 3+ proteinuria

• Diastolic BP ≥90 mmHg, 2+ proteinuria,

and any: severe headache, visual disturbance, epigastric pain Give antihypertensive medication to mother if systolic BP >160 mmHg

• Goal: keep BP <150/100 mmHg

Prepare to care for mother immediately after birth:

Confirm single baby only (not multiple birth) 1. Give oxytocin within 1 minute after birth 2. Deliver placenta 1-3 minutes after birth 3. Massage uterus after placenta is delivered 4. Confirm uterus is contracted

Prepare to care for baby immediately after birth:

1. Dry baby, keep warm

2. If not breathing, stimulate and clear airway 3. If still not breathing:

• clamp and cut cord • clean airway if necessary • ventilate with bag-and-mask • shout for help

Does mother need to start:

Antibiotics?

No Yes, given

Magnesium sulfate and antihypertensive treatment?

No

Yes, magnesium sulfate given

Yes, antihypertensive medication given

Confirm essential supplies are at bedside and prepare for delivery:

For mother Gloves

Alcohol-based handrub or soap and clean water

Oxytocin 10 units in syringe For baby

Clean towel Tie or cord clamp Sterile blade to cut cord Suction device

Bag-and-mask

Completed by

2

BEFORE BIRTH

This checklist is not intended to be comprehensive and should not replace the case notes or partograph. Additions and modifications to fit local practice are encouraged.

For more information on recommended use of the checklist, please refer to the “WHO Safe Childbirth Checklist Implementation Guide” at: www.who.int/patientsafety.

Assistant identified and ready to help at birth if needed.

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Soon After Birth (Within 1 Hour)

WHO Safe Childbirth Checklist

Is mother bleeding abnormally?

No

Yes, shout for help

Does mother need to start:

Antibiotics?

No Yes, given

Magnesium sulfate and antihypertensive treatment?

No

Yes, magnesium sulfate given

Yes, antihypertensive medication given

Does baby need:

Referral?

No

Yes, organized Antibiotics?

No Yes, given

Special care and monitoring?

No

Yes, organized

Started breastfeeding and skin-to-skin contact (if mother and baby are well).

Confirm mother / companion will call for help if danger signs present.

If bleeding abnormally:

• Massage uterus

• Consider more uterotonic

• Start IV fluids and keep mother warm

• Treat cause: uterine atony, retained placenta/fragments, vaginal tear, uterine rupture

Ask for allergies before administration of any medication Give antibiotics to mother if placenta manually removed or if mother’s temperature ≥38 °C and any of:

• Chills

• Foul-smelling vaginal discharge

If the mother has a third or fourth degree of perineal tear give antibiotics to prevent infection

Give magnesium sulfate to mother if any of:

• Diastolic BP ≥110 mmHg and 3+ proteinuria

• Diastolic BP ≥90 mmHg, 2+ proteinuria, and any: severe headache, visual disturbance, epigastric pain

Give antihypertensive medication to mother if systolic BP >160 mmHg

• Goal: keep BP <150/100 mmHg Check your facility’s criteria.

Give baby antibiotics if antibiotics given to mother for treatment of maternal infection during childbirth or if baby has any of:

• Respiratory rate >60/min or <30/min

• Chest in-drawing, grunting, or convulsions

• Poor movement on stimulation

• Baby’s temperature <35 °C (and not rising after warming) or baby’s temperature ≥38 °C

Arrange special care/monitoring for baby if any:

• More than 1 month early

• Birth weight <2500 grams

• Needs antibiotics

• Required resuscitation

Completed by

WHO Safe Childbirth Checklist

Responsibility for the interpretation and use of the material in this checklist lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. For more information visit www.who.int/patientsafety.

3

AFTER BIRTH

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Before Discharge

WHO Safe Childbirth Checklist

Confirm stay at facility for 24 hours after delivery.

Does mother need to start antibiotics?

No

Yes, given and delay discharge

Is mother’s blood pressure normal?

No, treat and delay discharge Yes

Is mother bleeding abnormally?

No

Yes, treat and delay discharge

Does baby need to start antibiotics?

No

Yes, give antibiotics, delay discharge, give special care

Is baby feeding well?

No, establish good breastfeeding practices and delay discharge Yes

Discuss and offer family planning options to mother.

Arrange follow-up and confirm mother / companion will seek help if danger signs appear after discharge.

Ask for allergies before administration of any medication Give antibiotics to mother if any of:

• Mother’s temperature ≥38 °C

• Foul-smelling vaginal discharge

Give magnesium sulfate to mother if any of:

• Diastolic BP ≥110 mmHg and 3+ proteinuria

• Diastolic BP ≥90 mmHg, 2+ proteinuria, and any: severe headache, visual disturbance, epigastric pain

Give antihypertensive medication to mother if systolic BP >160 mmHg

• Goal: keep BP <150/100 mmHg

If pulse >110 beats per minute and blood pressure <90 mmHg

• Start IV and keep mother warm

• Treat cause (hypovolemic shock)

Give antibiotics to baby if any of:

• Respiratory rate >60/min or <30/min

• Chest in-drawing, grunting, or convulsions

• Poor movement on stimulation

• Baby’s temperature <35°C (and not rising after warming) or baby’s temperature ≥38°C

• Stopped breastfeeding well

• Umbilicus redness extending to skin or draining pus

Danger Signs Mother has any of:

• Bleeding

• Severe abdominal pain

• Severe headache or visual disturbance

• Breathing difficulty

• Fever or chills

• Difficulty emptying bladder

• Epigastric pain

Baby has any of:

• Fast/difficult breathing

• Fever

• Unusually cold

• Stops feeding well

• Less activity than normal

• Whole body becomes yellow

Completed by

WHO Safe Childbirth Checklist

AFTER BIRTH

Responsibility for the interpretation and use of the material in this checklist lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. For more information visit www.who.int/patientsafety.

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THE WHO SAFE CHILDBIRTH CHECKLIST

WHO SAFE CHILDBIRTH CHECKLIST IMPLEMENTATION GUIDE 18 A copy of the WHO Safe Childbirth Checklist can be downloaded as a separate document,

and can be found on WHO and Ariadne Labs websites.

The WHO Safe Childbirth Checklist was developed according to WHO guidelines and inter- national standards of care. However, modifying the Checklist may be necessary to reflect contextual factors or national protocols and guidelines. If changes are necessary, please refer to the guiding principles on pages 23 and for some common context specific adaptations on page 58.

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WHO SAFE CHILDBIRTH CHECKLIST IMPLEMENTATION GUIDE 19

BACKGROUND AND OVERVIEW

IMPLEMENTING THE WHO SAFE CHILDBIRTH

CHECKLIST

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IMPLEMENTING THE WHO SAFE CHILDBIRTH CHECKLIST

WHO SAFE CHILDBIRTH CHECKLIST IMPLEMENTATION GUIDE 20 The way in which the Safe Childbirth Checklist (the Checklist) is introduced to health-care

workers is important. Experience with the WHO Surgical Safety Checklist and other ventures to improve safety and quality for patients across the globe has shown that simply introduc- ing a checklist to a facility will not lead to sustained improvement in essential health-care practices.5-7 Based on well-described models for behaviour change5-7 in health-care settings and using lessons learned from a range of stakeholders’ experiences, the following three key steps can help each facility or system achieve the best results:

With appropriate engagement, launch and ongoing support, the Checklist can change indi- viduals’ and facilities’ practices for the better, as well as create system-wide improvements and awareness about patient safety. These changes can, in turn, lead to improved quality of care for both mothers and newborns.

The Checklist Alone is Not Enough

Engagement with leadership, a checklist launch and ongoing support can help achieve successful outcomes.

ENGAGE: Gaining buy-in and establishing a team to support implementation • Ensuring buy-in and stakeholder understanding of the Checklist

• Establishing a team to take ownership of the Checklist • Reviewing current resources and practices to determine what is needed for the Checklist to be successful

• Adapting the Checklist to fit local guidelines and protocols

LAUNCH: Event to introduce the WHO Safe Childbirth Checklist • Launching the WHO Safe Childbirth Checklist through

an official event or training

• Incorporating technical training to address gaps in practice

SUPPORT: Encouraging use through coaching, monitoring and evaluation • Discussing Checklist use and showcasing people in the facility using the Checklist • Observing Checklist use and using coaching skills to give respectful and

constructive feedback to encourage change and motivate adherence • Documenting successes and challenges by gathering information on use of the Checklist, essential birth practice behaviours and supply availability • Sharing information regularly to encourage improvement.

After launching the Checklist, a continuous cycle of coaching, performance measurement, and data feedback helps lead to improved standards and quality of care.

IMPLEMENTING THE WHO SAFE CHILDBIRTH CHECKLIST

THE CHECKLIST

ENGAGE LAUNCH

SUPPORT

Strengthened Individual

& System Standards

Improved Maternal &

Neonatal Quality of Care RESULTS

DAT A FEE

DBACK MEASUREMENT COACHING

LEADING TO FROM THE FIELD

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WHO SAFE CHILDBIRTH CHECKLIST IMPLEMENTATION GUIDE 21

IMPLEMENTING THE WHO SAFE CHILDBIRTH CHECKLIST

1 Engage

Using the WHO Safe Childbirth Checklist successfully for every delivery leads to safer and better care for mothers and newborns. However, you can only achieve such consistent Checklist use if birth attendants and health-care leaders believe in and actively support implementation of the WHO Safe Childbirth Checklist.

In order to reach this belief and gain support, influential individuals, institutions and orga- nizations should come together early on in the effort to begin using the Checklist. Other important partners may include government officials, local and national administrative staff, and even patients. Convincing these stakeholders that the WHO Safe Childbirth Checklist can improve the quality of health care and the safety of mothers and newborns will improve the chances of successfully introducing the Checklist into a facility or health system.7

IDENTIFY WHICH INDIVIDUALS, INSTITUTIONS, OR ORGANIZATIONS MUST GIVE APPROVAL OR SUPPORT FOR USING THE WHO SAFE CHILDBIRTH CHECKLIST It is important to gain the public endorsement of key individuals, institutions, and organizations to ensure effective implementation of the Checklist. Engagement with different health administrative levels is especially important to ensure that they are aware of your process for implementing the Checklist. By publicly embracing the process and providing the resources required, these leaders send a powerful message of support for adoption of the Checklist that will in turn motivate health-care staff to use it. Understanding whom to engage is the first step to successfully implementing the Checklist.In many institutions, physicians are not employees, but private contrac- tors who work in the institutions. It is important to get their buy-in early on, as merely sending a directive to use the Checklist is unlikely to be successful.

1. Identify which individuals, institutions, or organizations must give approval or support for using the Checklist

2. Organize a meeting to describe and explain the Checklist

3. Establish a team made up of appropriate health-care leaders and birth attendants to guide implementation of the Checklist

4. Review available resources and current practices to determine how the Checklist can best be used and what needs must be fulfilled to ensure success 5. Customize the Checklist appropriately to make it more relevant to your local

facility and health-care system

THE ENGAGE PROCESS INVOLVES THE FOLLOWING FIVE STEPS8

1

Experience from the WHO Collab- oration indicates that leadership engagement was critical for staff to begin using the Checklist

FROM THE FIELD

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IMPLEMENTING THE WHO SAFE CHILDBIRTH CHECKLIST

WHO SAFE CHILDBIRTH CHECKLIST IMPLEMENTATION GUIDE 22 ORGANIZE A MEETING TO DESCRIBE AND EXPLAIN THE CHECKLIST

In order to gain the support of health-care leaders, birth attendants and other participants, you must first explain what the Checklist is, how it works, and why each item on the Checklist is so important.

ESTABLISH A TEAM MADE UP OF APPROPRIATE HEALTH-CARE LEADERS AND BIRTH ATTENDANTS TO GUIDE THE IMPLEMENTATION OF THE CHECKLIST General support for the use of the Checklist is not enough. You must next decide who will be directly responsible for guiding the implementation process to success.

At a national or state level, a working group, a responsible institution or organization, or a team can guide implementation of the Safe Childbirth Checklist. At the facility level, select one or more birth attendants to be guides or “champions” of the process.

The champions can come from a variety of health-care professions. Champions should take an active role in managing each step of the implementation process.

Your team may benefit from inviting a member from the next health administrative level such as a district or regional health office. This may be valuable especially in the beginning of the implementation process and can help other facilities decide to implement the Checklist as well.

REVIEW AVAILABLE RESOURCES AND CURRENT PRACTICES TO DETERMINE HOW THE CHECKLIST CAN BEST BE USED AND WHAT NEEDS MUST BE FULFILLED TO ENSURE SUCCESS At the start of the implementation process, leaders should collect data on what supplies, guidelines/policies, infrastructure-related issues (i.e. hand washing stations) are available at the facility and what practices are in place.

This data will serve many purposes: it will reveal ways in which the facility can improve its care, and help measure improvement after the implementation process has begun. It may also help motivate staff to change their practices as the process is on-going. Thus, leaders should be extremely careful to collect these data in a sympathetic and non-threatening manner. Staff should know that the aim is to improve quality of care for mothers and newborns.

Without essential supplies, it is not possible to successfully introduce the Checklist into a facility or health-care system. A list of safe birth supplies required for successful use of the Checklist is included in the annexes. This may be used to conduct an initial assessment of resources, as well as for regular monitoring, to ensure that the necessary supplies are always available. Knowing which items are and which are not performed in facilities before the Checklist is to be introduced allows leaders to provide more support for those items that require it. An initial well-documented assessment may help to advocate for better procurement and supply chain management at the national level.

CUSTOMIZE THE CHECKLIST APPROPRIATELY TO MAKE IT MORE RELEVANT TO YOUR LOCAL FACILITY AND HEALTH-CARE SYSTEM The Checklist was developed according to WHO guidelines and international standards of care, so modifying the Checklist too much may make it less effective. However, you may need to make changes to the Checklist to reflect contextual factors such as prevalence of HIV

2 3

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WHO SAFE CHILDBIRTH CHECKLIST IMPLEMENTATION GUIDE 23 or a risk of malaria, for example. In this case, it is important for the implementation team to

interact with the national level and advocate for a nationwide review of the WHO Safe Child- birth Checklist. A national convening of experts could review the Checklist to ensure accor- dance with national standards, guidelines and culture and modify the Checklist accordingly.

The Checklist should be translated into the local language in order to make it easy to use.

As with modifications to the Checklist, it is important to coordinate translations at the nation- al level. This will prevent duplication of work if other facilities in the region or country are also implementing the Checklist.

If it is necessary to modify the Checklist further to suit the local setting, working with local health-care leaders, birth attendants, and other participants will allow everyone to share in the success. Knowing that their facility or colleagues participated in the process of modifying the Checklist may contribute to others’ willingness to use it.

You should remember that checklists are most useful when they are easy to use.

If you must modify the Checklist, for example, adding items relating to HIV or malaria to make the Checklist more specific to your context, consider the guiding principles below:

Using fewer items. Many facilities struggle with the temptation to include too many items in their Checklist, but remember that each new item will make the Checklist more difficult to use.

Every item on the Checklist should fit at least one of these statements:8

Serious consequences can result if it is missed out

It needs to be done, but is commonly missed

It improves communication between team members

Using language that is comfortable and simple. Using clear, straightforward language that feels ‘right’ when said aloud. When items are written in a language that is not comfortable or simple, people are less likely to use the Checklist.

Using a simple and easy-to-read design. Using consistent formatting and not using small, crowded text. If the Checklist is unclear and therefore difficult to read, people are unlikely to use it.

Modifying the Checklist

Each member of the WHO Collaboration who participated in the Evaluation and also reported ongoing use of the Checklist, also reported making modifications to the Checklist.

A few facilities also indicated that they asked obstetrician/gynaecology experts across their respective countries to help adapt the Checklist.

Examples of Checklist modifications included inserting a space to include the mother’s name, blood pressure and temperature results; adding the facility’s specific criteria for referral of the mother or newborn to a higher-level facility; adding a check for allergies; and adding prevention of mother-to-child transmission (PMTCT)-related activities such as HIV testing and administration of antiretrovirals.

FROM THE FIELD

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WHO SAFE CHILDBIRTH CHECKLIST IMPLEMENTATION GUIDE 24

Launch

Launching the WHO Safe Childbirth Checklist through an official event or training is import- ant to establish the importance of using the Checklist. Key stakeholders at the local level can train others at their facility after they are trained through a training-of-trainers that takes place at a higher health administrative level.

Independent of the type of format you choose for the local level, the event can be led by the designated implementation or management team established in the ‘Engage’ phase.

However, active participation from staff across different disciplines is encouraged, including physicians. Such an event can further engage health-care staff and administrators, provide the opportunity for additional technical training on childbirth practices and provide a forum for discussing barriers and enablers. You should inform the next health administrative level about the event and invite them to help formalize the launch.

The event should create an atmosphere of excitement for birth attendants and other staff.

You may wish to include materials such as handouts and lectures, or create an instructional or motivational video. Hands-on simulation using props or training participants as mock patients is an essential component of adult learning and training.

1. Introduce yourself and the team guiding the implementation of the WHO Safe Childbirth Checklist 2. Introduce the benefits of using a checklist

3. Explain the four pause points of the WHO Safe Childbirth Checklist 4. Demonstrate and explain the proper

use of the Checklist using mock performances, videos, and other materials

5. Give participants the opportunity to practice using the Checklist

6. Encourage participants to discuss the potential challenges to using the Checklist

7. Invite participants to share their thoughts and feelings about the Checklist and answer any ques- tions they raise

8. Let the participants know they have your support and the team’s ongoing support throughout implementation of the Checklist

A LAUNCH SHOULD INCORPORATE THE FOLLOWING STEPS8

Include Technical Training Sessions

Most Collaboration members included a technical training on subjects such as hand hygiene and partograph use. Their teams reviewed the resources available and the practices in use in their facilities (as described in the

‘Engage’ process) in order to decide which trainings to include in their launch events.

Many Collaboration sites reported using simulation and conducting a training initially for obste- tricians and senior nurses or midwives to gain buy-in and equip them to then be able to train oth- ers. The BetterBirth programme used instructional and motivational videos to guide facility staff on how to use the Checklist and empha- size its importance.

FROM THE FIELD IMPLEMENTING THE WHO SAFE CHILDBIRTH CHECKLIST

A guide for the launch event can be found in the annexes. Additionally, a set of images to describe each of the pause points in the Checklist, also found among the annexes, can be helpful to display and reference during a launch training event. In the days following the launch event, implement- ers and/or selected facility staff are encouraged to be readily available to answer questions.

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WHO SAFE CHILDBIRTH CHECKLIST IMPLEMENTATION GUIDE 25

Support

Implementers and facility leaders are encouraged to provide support by continuously promoting the Checklist to create awareness of and enthusiasm about its use. For example, taking advantage of regularly scheduled meetings is useful to emphasize the importance of using the Checklist and discussing progress to date. Additionally, using photos, videos and message boards to showcase people using the Checklist helps make its implementation more meaningful and reinforces the idea that it is being led locally and is customized for the local setting.

Two essential components of support are coaching others to encourage change and using monitoring and evaluation for improvement.

COACHING OTHERS TO ENCOURAGE CHANGE8

Coaching is an important component of successful checklist implementation. It helps lead individuals and teams towards better performance and helps sustain effective checklist use over time. Coaching colleagues and staff on checklist use is about observing, encouraging and giving people respectful and constructive feedback to shape new behaviour and improve performance.

Coaching involves meeting people where they are in their practice and helping them to improve.

A coach can be any individual or a group of individuals from a variety of clinical and/or admin- istrative backgrounds, from any level within the facility or outside. A coach can coach others full-time or part-time in addition to having other responsibilities. A coach can be, but does not have to be, a senior member of the facility. Coaches can also come from a higher health admin- istration level to support a number of facilities or districts with implementation of the Checklist.

Coaching involves observing others during a delivery to assess adherence to the Checklist.

It may also mean reviewing completed checklists to ensure that they were filled in completely and correctly. Giving respectful and constructive feedback on both observations of deliveries and completed checklists are important components of coaching. To motivate others and give appropriate feedback, good communication is critical. Good coaches know how and when to listen, speak to others with respect and kindness, and communicate ideas clearly and simply.

See the Principles for Effective Coaching in the annexes to learn more about the qualities and skills of effective coaching and helpful communication techniques for giving constructive feedback.

While helping to establish and maintain proper Checklist use in the facility, coaching can help support a number of improvements:

BETTER, COORDINATED PATIENT CARE. Teams that function well take better care of patients

BETTER MORALE. Coaching on Checklist use will help to reinforce best practices that keep communication and teamwork at a high level

DISCOVERY OF OTHER OPPORTUNITIES. Coaching can help identify new opportunities for improvement

LONG-TERM SUCCESS. Coaching can show that what people do matters and that there is an investment in their continued success

In order to facilitate change, a coach must understand what keeps others from improving their practices. A coach is likely to witness three factors9 that make it difficult for others to perform the items on the Checklist:

A GOOD COACH IS SOMEONE WHO IS:

• Coachable

• Respected

• Humble

• Patient

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WHO SAFE CHILDBIRTH CHECKLIST IMPLEMENTATION GUIDE 26 MONITORING AND EVALUATION FOR IMPROVEMENT

In order to provide birth attendants with ongoing encouragement and support in using the WHO Safe Childbirth Checklist, you must first know when, how, and why birth attendants are (or are not) using the Checklist in their work. Measuring how often and how well birth attendants use the Checklist and deliver the essential birth practices on the Checklist can tell you what they find difficult about using the Checklist, allow you to seek help with solving those challenges, and identify personal and facility improvements to celebrate with the team and more broadly. Remember that the Checklist can be integrated within the facility’s existing health processes and quality improvement efforts and does not have to be an additional task.

It is important to assess how the Checklist can complement or enhance the systems in place.

Monitoring the implementation process

Coaches, supervisors and birth attendants, may gather information on use of the Checklist and on the quality of care delivered by making direct observations of others conducting birth practices. In the annexes, you will find an Observation Tool that can allow an observer to:

Challenges in Using the Checklist

The WHO Safe Childbirth Checklist Collaboration evaluation revealed a number of motivational challenges in using the Checklist, such as the belief that the Checklist was too complex and took too much time. Coaches were able to address these challenges by conducting ongoing supervision and training, and reinforcing the importance of the Checklist through education and staff-wide meetings.

Many WHO Collaboration sites also faced challenges related to skills, both in using the Check- list and in certain birth practices advocated on the Checklist. Successful sites held additional launch events and technical trainings to help increase skills.

Across the WHO Collaboration, a common opportunity challenge included a lack of essential supplies. In this case, many coaches and birth attendants worked with facility managers and even higher level health administrators to develop a stronger supply chain. In facilities where birth attendants did not readily have access to copies of the Checklist, because the facility had no printer, sites considered making posters. Each pause point poster of the Checklist was placed in the room where the care was delivered for that pause point. Some facilities created a few laminated copies of the Checklist that could be wiped clean and reused for each delivery.

To address staff shortages and inconsistent attendance, many sites focused on attendance policies and encouraged health-care workers to use birth companions for assistance, when appropriate.

FROM THE FIELD

OPPORTUNITY

Environmental or contextual factors beyond an individual’s control

(For example: leadership support challenges, human resource or supply constraints)

MOTIVATION

Interest or internal belief

ABILITY

Skill, knowledge, or technical confidence

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WHO SAFE CHILDBIRTH CHECKLIST IMPLEMENTATION GUIDE 27

Document what practices the birth attendants perform during each observation period

Decide which practices are the most important for your facility or health-care system to improve on

Make sure all observers watch for and document the same kinds of practices and behaviours

Decide and document the main reason for a birth attendant not completing a Checklist item (Lack of opportunity, ability or motivation)

The purpose of the Observation Tool is not to judge birth attendants’ performance, and so you must make certain that they know that the observations are for data collection for coaching and quality improvement only. Additionally, it is helpful to avoid using names or other informa- tion that can identify birth attendants or patients on the observation tools to further increase provider buy-in for the process. You may want to include supervisors from the next health administrative level in this process: they may be able to observe practices more objectively and provide useful comments compared to those that staff always present at the facility would perhaps not see. No matter what observation tool you use, all of the observers must agree on the definitions of specific items on the Checklist, for example when is a “mother’s bleeding successfully controlled?”

In addition to the Observation Tool, the Checklist itself can also be used to monitor and docu- ment the kind of care offered by birth attendants. By reviewing completed Checklists, you can see whether and how the quality of care in your facility or health-care system is evolving.

When you discuss results with birth attendants and leadership, you should do so using the Principles of Effective Coaching in the annexes, so birth attendants feel that you are supporting them in improving their practices rather than pressuring them to “check the box.”

Because specific equipment and supplies are necessary to delivering the essential birth practices on the Checklist, regularly monitoring their availability in your facility is important. You will find a sample Safe Birth Supplies Tool, in the annexes, that can be used to help facilities monitor their supplies, identify needs, and notice areas for improvement.

Evaluation and feedback for improvement

After you collect data on your facility’s use of the Checklist and quality of care, it is important to take steps to learn lessons from the data and then share those lessons with birth attendants and others using the Checklist in their work. At a health system level, data can be collected from and aggregated across many facilities to analyze regional or national trends in maternal and neonatal health.

Storing data in a paper- or computer-based spreadsheet will allow you to organize data and find trends. You might ask some or all of the following questions:

How is use of the Checklist changing over time?

Which specific Checklist items are more likely to be completed? Which are less likely to be?

What supplies and equipment are routinely missing? Why? How can the supplies be available more consistently?

Why do birth attendants commonly not complete specific Checklist items?

How can these challenges be overcome?

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WHO SAFE CHILDBIRTH CHECKLIST IMPLEMENTATION GUIDE 28 Regardless of the details, such as which document you use or what kind of spreadsheet you

create, you will find data feedback and reporting to be crucial to success. Everyone involved in using the Checklist – birth attendants, facility and health-care leaders, and coaches – must understand when and how to make changes to solve ongoing challenges. This will require asking the birth attendants and facility leaders questions to understand how and why there are challenges and engaging them in helping to solve system level challenges as well as provide motivation to each other.

Additionally, successes should be shared with everyone regularly in order to encourage them to continue the practices that work well. In the annexes, you will find a Coaching Tool that can be helpful for recording successes and challenges, as well as preparing for data-sharing conversations with birth attendants or others. You may also find this tool useful in recognizing staff that have contributed to success, or for creating a plan to resolve specific challenges. Many successful quality improvement programmes give social recognition to those who are positive leaders in the implementation process.

How to Use the Data Visualizations

Experience from the BetterBirth trial and the WHO Collaboration indicate that visually displaying data at a facility can empower staff by demonstrating where challenges to Checklist use still remain and where the facility is improving.

VISUALLY DISPLAYING YOUR DATA

BAR CHARTS LINE CHARTS

BEHAVIOUR LOGS

OR

PIE CHARTS

SAMPLE BEHAVIOURS 1 2

OBSERVATIONS

3 4 5 6 7 8 9 10

1 2

OBSERVATIONS

3 4 5 6 7 8 9 10

SAMPLE BEHAVIOURS

Mother’s blood pressure taken

Oxytocin given within 1 minute of birth

Skin-to-skin contact

Danger signs explained

Mother’s blood pressure taken

Oxytocin given within 1 minute of birth

Skin-to-skin contact

Danger signs explained

While data visualizations are often computer-generated tables, charts, and graphs, you may also hand-draw them.

Using color is a simple way to show progress (red to indicate “no” or a negative trend, green to indicate “yes” or a positive trend). Below are examples of data visualizations that will help show progress and tell the story of the implementation process:

FROM THE FIELD IMPLEMENTING THE WHO SAFE CHILDBIRTH CHECKLIST

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WHO SAFE CHILDBIRTH CHECKLIST IMPLEMENTATION GUIDE 29

BACKGROUND AND OVERVIEW

ANNEXES

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WHO SAFE CHILDBIRTH CHECKLIST IMPLEMENTATION GUIDE 30

Safe Birth Supplies

Date Date Date Date Date

WHAT ARE SAFE BIRTH SUPPLIES?

Supplies required to safely and hygienically manage the process of labor and delivery as outlined by the items and practices of the WHO Safe Childbirth Checklist.

TO USE:

1. Start at the first available column. Write today’s date at the top of the column.

2. Look for each item on the list.

• Fill in circle “Y” if that supply, equipment, or medication is working, not expired, and readily available to birth attendants.

• Fill in circle “N” if that supply, equipment, or medication is broken, expired, or otherwise unavailable to birth attendants.

GENERAL SUPPLIES AND EQUIPMENT

Power Supply Y N Y N Y N Y N Y N

Clean Water Y N Y N Y N Y N Y N

Soap or Alcohol Hand Rub Y N Y N Y N Y N Y N

Disinfectant Y N Y N Y N Y N Y N

Autoclave Y N Y N Y N Y N Y N

Clean Gloves Y N Y N Y N Y N Y N

Stethoscope Y N Y N Y N Y N Y N

Thermometer Y N Y N Y N Y N Y N

Blood Pressure Instrument Y N Y N Y N Y N Y N

Partograph Y N Y N Y N Y N Y N

Fetoscope/Doppler Y N Y N Y N Y N Y N

SUPPLIES IN THE DELIVERY ROOM

Suction Machine Y N Y N Y N Y N Y N

Mucus Extractor Y N Y N Y N Y N Y N

Neonatal Bag-and-Mask Y N Y N Y N Y N Y N

Oxygen Cylinder/Concentrator Y N Y N Y N Y N Y N

Baby Scale Y N Y N Y N Y N Y N

Needle/Syringe Y N Y N Y N Y N Y N

Urine Dip Sticks Y N Y N Y N Y N Y N

Sterilized Blade/Scissor Y N Y N Y N Y N Y N

Cord Tie/Clamp Y N Y N Y N Y N Y N

Clean Pads for Mother Y N Y N Y N Y N Y N

Clean Towel Y N Y N Y N Y N Y N

MEDICATIONS/INJECTIONS/DRIPS

Bag of IV Fluids Y N Y N Y N Y N Y N

Injectable Oxytocin Y N Y N Y N Y N Y N

Injectable Magnesium Sulfate Y N Y N Y N Y N Y N

Antibiotics for Mother Y N Y N Y N Y N Y N

Antibiotics for Infant Y N Y N Y N Y N Y N

Antihypertensives Y N Y N Y N Y N Y N

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